Staging of mental disorders: systematic review

Interpreting and operationalizing the incurability requirement in Canada's assisted dying legislation

To access medical assistance in dying (MAiD) in Canada, a person must have a "grievous and irremediable medical condition" defined in part as "a serious and incurable illness, disease, or disability". Thus, the clinical assessment of the incurability of a person's condition is central to determining MAiD eligibility. However, the clinical interpretation and operationalization of the term have been uncertain due to the absence of a clear legal definition and evolving legislation. This has led to confusion and controversy in the public and professional discussion of MAiD eligibility. In this paper, we examine various attempts to interpret and operationalize the term "incurable", identifying the limitations of each approach. We aim to overcome these limitations by proposing a method for operationalizing the term. We argue that our approach: (1) is consistent with the current legal framework, (2) is consistent with the interpretations of the terminology used in the Criminal Code, and (3) reflects the clinical knowledge and reasoning about the full range of medical conditions that can lead to a request for MAiD. In our analysis, we show that incurability cannot be understood only as a feature of a person's medical condition but resides in the interplay between the nature of the pathology and the person's treatment decision-making. Our analysis should help with the ongoing operationalization of the incurability requirement in Canada. It may also be helpful to clinicians in other jurisdictions that either invoke or are considering invoking similar terms/concepts.

The association between adverse experiences and longitudinal allostatic load changes with the depression symptoms trajectories in middle-aged and older adults in China: A longitudinal study

BACKGROUND

This study investigated the associations between adverse childhood experiences (ACEs), adverse adulthood experiences (AAEs), allostatic load (AL) changes, and later depression symptoms trajectories in middle-aged and older Chinese longitudinally.

METHODS

1921 individuals aged ≥45 years at baseline were included from the China Health and Retirement Longitudinal Study (CHARLS). Measures included ACEs, AAEs, depression symptoms scores, health-related factors, and demographic characteristics. AL changes were assessed by the difference in AL scores between wave 3 (2015) and wave 1(2011).

RESULTS

Compared to consistently low trajectory, 2 or more ACEs (OR 1.78, 95 % CI 1.28-2.46), 2 or more AAEs (OR 1.82, 95 % CI 1.26-2.64), decreasing metabolic AL over time (OR 0.63, 95 % CI 0.46-0.86), increasing inflammatory AL over time (OR 1.60, 95 % CI 1.07-2.37), and decreasing renal AL over time (OR 1.38, 95 % CI 1.01-1.87) were associated with the low-moderate depression symptoms trajectory. Furthermore, 2 or more ACEs (OR 1.48, 95 % CI 1.10-2.00), 2 or more AAEs (OR 1.85, 95 % CI 1.32-2.60), decreasing metabolic AL over time (OR 0.75, 95 % CI 0.57-1.00), increasing inflammatory AL over time (OR 1.69, 95 % CI 1.19-2.42) were associated with the high-moderate depression symptoms trajectory.

CONCLUSION

Experiencing more ACEs and AAEs was associated with higher depression symptoms trajectories. Moreover, participants with decreasing metabolic AL over time showed a low depression symptoms trajectory, while those with increasing inflammatory AL over time and decreasing renal AL over time showed a worse depression symptoms trajectory. These findings highlighted the physiological damage caused by stress on mental health outcomes.

Longitudinal trends of body composition in Anorexia Nervosa: Cardiac functioning impacts the restoration of fat-free mass at three-months follow-up

BACKGROUND AND AIMS

Predictors of outcomes are needed in order to improve the clinical management of patients with Anorexia Nervosa (AN). The present study evaluated whether cardiac dysfunction might be associated with different longitudinal outcomes of AN.

METHODS AND RESULTS

A sample of 35 patients with AN (11 restricting, 24 binge-purging- age range 16-28 years old) and 42 healthy controls (18-29 years old) were evaluated in terms of psychometric variables, Body Mass Index (BMI), body composition (by bioimpedance analysis, namely: Fat-Free Mass - FFM, Fat Mass - FM, Body Cell Mass - BCM, Phase Angle - PhA) and cardiac functioning (left ventricular ejection fraction - LVEF; global longitudinal strain - LVGLS). FM was significantly and negatively associated with eating psychopathology (weight and shape concerns, b -0.523, p 0.029; and shape concerns b -0.578, p0.015), while cardiac dysfunction (LVGLS > -18%) was positively associated with dietary restraints (b 1.253, p 0.043). LVEF, in turn, was positively associated with BCM (b 0.721, p 0.008) and FFM (b 0.779, p 0.039). Cardiac dysfunction negatively impacted the effect of nutritional rehabilitation, as those patients reporting reduced LVGLS showed lower FFM (b -4.410, p 0.011), FM (b -1.495, p 0.003) and BCM (b -2.205, p 0.015) at follow-up after three months.

CONCLUSION

These preliminary results showed that cardiac functioning might represent an early predictor of cachexia and chronicity, while body composition seems to be a more accurate measure for evaluating the recovery process of patients with AN.

The progress in the field of clinical staging for mental disorders within the last decade: an updated systematic review

Introduction

Clinical staging aims to refine psychiatric diagnosis by describing mental disorders on a continuum of disorder progression, with the pragmatic goal of improved treatment planning and outcome prediction. The first systematic review on this topic, published a decade ago, included 78 papers, and identified separate staging models for schizophrenia, unipolar depression, bipolar disorder, panic disorder, substance use disorder, anorexia, and bulimia nervosa. The current review updates this review by including new proposals for staging models and by systematically reviewing research based upon full or partial staging models since 2012.

Methods

PsycINFO, MEDLINE, EMBASE, and the Cochrane databases were systematically searched from 2012 to June 2023. The original review's eligibility criteria were used and extended with newly introduced categories of DSM-5 mental disorders, along with mental disorders for which a progressive course might be expected. Included papers: a) contained a complete or partial staging model, or b) focused upon clinical features that might be associated with stages, or c) focused upon treatment research associated with specific stages.

Results

Seventy-one publications met the inclusion criteria. They described staging models for schizophrenia and related psychoses (21 papers), bipolar (20), depressive (4), anxiety (2), obsessive-compulsive (3), trauma related (4), eating (3), personality disorders (2), and 'transdiagnostic' staging models (13).

Discussion

There is a steady but slow increase in interest in clinical staging and evidence for the validity of staging remains scarce. Staging models might need to be better tailored to the complexities of mental disorders to improve their clinical utility.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42021291703.

Intervention Programmes for First-Episode Psychosis: A Scoping Review

The aim of this scoping review was to map intervention programmes for first-episode psychosis by identifying their characteristics, participants, and specific contexts of implementation. It seems reasonable to suggest that early intervention may be beneficial in improving recovery outcomes and reducing the duration of untreated psychosis (DUP). Despite the expansion of these programmes, there are still some significant variations and barriers to access that need to be addressed. In line with the Joanna Briggs Institute (JBI) methodology and the Participants, Concept, and Context (PCC) framework, this review encompasses studies focusing on individuals grappling with early-stage psychosis and their caregivers across a range of settings, including hospital and community environments. The review identified 47 studies from 2002 to 2023, which revealed a great deal of diversity in programme characteristics and implementation contexts. This reflects a global perspective. The results showed that there is a great deal of variety in the characteristics of the programmes, with interventions ranging from single-component strategies, such as cognitive-behavioural therapy (CBT) and cognitive remediation therapy (CRT), to multicomponent programmes that integrate a number of different approaches, including psychosocial, pharmacological, and family-focused strategies. The objectives included attempts to improve cognitive functioning; enhance coping skills; reduce caregiver burden; and address symptoms such as anxiety, depression, and hallucinations. It is notable that there was considerable variation in the frequency, duration, and follow-up periods of the interventions, with some lasting just three sessions over one month and others spanning five years and 48 sessions. The majority of the programmes were delivered in community or outpatient settings, although there were also examples of hospital- and home-based interventions. These findings highlight the value of early interventions and provide a useful resource for adapting programmes to different social and cultural contexts. It would be beneficial for future research to explore how these interventions can be tailored to diverse settings.

Clinical Staging for Personality Disorders in Older Adults

OBJECTIVE

This scientific research aimed to investigate the feasibility of implementing a clinical staging (CS) model for personality disorders (PDs) in older adults. The CS model could provide valuable insights into the life course of personality pathology, prognosis, and treatment decisions for PDs in older adults.

METHODS/DESIGN

The study employed an international Delphi methodology with three rounds and involved 21 experts.

RESULTS

Consensus was achieved on 12 out of 17 statements, confirming the viability of a CS model for PDs in older adults. The proposed model incorporates the Alternative Model for PDs, criterion A, and integrates life course information, distinguishing between chronic PD, re-emergent PD, late-onset PD, and past PD.

CONCLUSION

The findings suggest that international experts support the implementation of a CS model for PDs in older adults, considering both the severity of personality functioning and the retrospective life course of PD expression.

Can people with longstanding bulimia nervosa suffer from severe and enduring eating disorder? A qualitative study

OBJECTIVES

To interview a series of individuals with bulimia nervosa of longstanding to establish their symptoms and examine the suggestion, using qualitative analysis, that the term "Severe and Enduring Bulimia Nervosa (SEED-BN)" might be appropriate and helpful.

METHODS

12 participants with Bulimia Nervosa, one male, were interviewed with the help of an interview guide. Interviews were recorded and transcribed. Transcripts were analysed using Thematic Analysis.

RESULTS

Participants with Bulimia Nervosa described serious problems in many realms, especially social, psychological, family and relationships.

CONCLUSIONS

Bulimia nervosa of long duration is associated with many serious symptoms. It seems likely that recognition of long-standing bulimia nervosa as a severe and enduring eating disorder could encourage clinicians and families to pay attention to the wide variety of problems suffered by this group. Further research is required to examine this proposal.

Psychological features of systemic sclerosis: results from an observational study

Objectives

(a) Assessing mental disorders, psychological distress, psychological wellbeing in patients with systemic sclerosis (SSc); (b) identifying psychological features independently contributing to the status of having the diagnosis of SSc.

Methods

Two hundred SSc outpatients were compared with 100 healthy subjects. Mental disorders were assessed via the Mini International Neuropsychiatric Interview (MINI). Self-reported rating scales were administered: Health Assessment Questionnaire Disability Index (HAQ-DI), Symptom Checklist-90-Revised (SCL-90-R), Psychological Well Being scales (PWB). General linear models allowed to verify which psychological feature would individually make unique contributions to overall status of having the diagnosis of SSc.

Results

Major depressive episode/disorder, panic disorder were more prevalent among patients with SSc (p < 0.05); SCL-90-R somatization and depression were more severe (p < 0.05) in SSc; PWB personal growth, positive relationships with others, purposes in life were poorer (p < 0.05) in patients with SSc if compared to healthy controls. The final general linear model, accounting for 20.4% of variance, showed that having the diagnosis of SSc was associated to lower SCL-90-R paranoid ideation and poorer PWB relationships with others.

Conclusion

SSc showed to present psychological features in need of assessment since some of them individually made unique contributions to overall status of having the SSc diagnosis.

Enduring effects of psychotherapy, antidepressants and their combination for depression: a systematic review and meta-analysis

Introduction

Although depressive disorders are frequently associated with relapses, the sustained efficacy of therapies after their termination has been insufficiently investigated.

Objective

The aim of this study was to evaluate the current evidence of enduring effects of psychotherapy, antidepressants and their combination after the end of treatment.

Methods

PubMed and PsychINFO were systematically screened according to PRISMA guidelines (except for preregistration). Only randomized controlled trials (RCTs) between 1980 and 2022 comparing the efficacy of psychotherapy, antidepressants and their combination in adult depression at follow-up at least 12 months after termination of therapy, which could be acute phase, maintenance or relapse prevention therapy, were included. Risk of bias was assessed by using the Cochrane risk of bias tool.

Results

In total 19 RCTs with a total of 1154 participants were included. Psychotherapy was significantly superior to pharmacotherapy regarding relapse rates and Beck Depression Inventory scores at follow-up after acute treatment in two of nine RCTs. Combined treatment performed significantly better than pharmacotherapy, but not psychotherapy, regarding relapse and remission in five out of nine RCTs at least 12 months after treatment termination. Pairwise meta-analyses indicated a superiority of combined treatment compared to pharmacotherapy alone regarding relapse, recurrence, and rehospitalization rates (RR=0.60, 95%-CI: 0.37-0.97, p=.041) and for psychotherapy compared to pharmacotherapy alone regarding relapse and recurrence rates (RR=0.58, 95%-CI: 0.38-0.89, p=.023), however comparative treatment effects between psychotherapy and combined treatment were insignificant.

Conclusions

Current findings suggest a superiority of psychotherapy and combined treatment over pharmacotherapy alone in major depressive disorder depression. Major limitations were a low number of studies reporting follow-up data after termination of study periods and a heterogeneity in definitions of treatment outcomes. Practice guidelines and participatory decision-making processes for the choice of treatment should consider the current knowledge on long-term effects of antidepressant therapy methods more than has been the case to date.

Prioritization of Psychopathological Symptoms and Clinical Characterization in Psychiatric Diagnoses: A Narrative Review

Importance

Psychiatry mainly deals with conditions that are mediated by brain function but are not directly attributable to specific brain abnormalities. Given the lack of concrete biological markers, such as laboratory tests or imaging results, the development of diagnostic systems is difficult.

Observations

This narrative review evaluated 9 diagnostic approaches. The validity of the DSM and the International Classification of Disorders (ICD) is limited. The Research Domain Criteria is a research framework, not a diagnostic system. The clinical utility of the quantitatively derived, dimensional Hierarchical Taxonomy of Psychopathology is questionable. The Psychodynamic Diagnostic Manual Version 2 follows psychoanalytic theory and focuses on personality. Unlike the personality assessments in ICD-11 or DSM-5's alternative model, based on pathological extremes of the big 5 traits (extraversion, agreeableness, openness, conscientiousness, and neuroticism), it lacks foundation in empirical evidence. Network analytic approaches are intriguing, but their complexity makes them difficult to implement. Staging would be easier if individually predictive biological markers were available. The problem with all these new approaches is that they abstract patient experiences into higher-order constructs, potentially obscuring individual symptoms so much that they no longer reflect patients' actual problems.

Conclusions and Relevance

ICD and DSM diagnoses can be questioned, but the reality of psychopathological symptoms, such as hallucinations, depression, anxiety, compulsions, and the suffering stemming from them, cannot. Therefore, it may be advisable to primarily describe patients according to the psychopathological symptoms they present, and any resulting personal syndromes, embedded in a framework of contextual clinical characterization including personality assessment and staging. The DSM and ICD are necessary for reimbursement, but they should be simplified and merged. A primarily psychopathological symptoms-based, clinical characterization approach would be multidimensional and clinically useful, because it would lead to problem-oriented treatment and support transdiagnostic research. It should be based on a universally used instrument to assess psychopathology and structured clinical characterization.

Phase-Based Care in Community Mental Health: A Cost-Effective Innovation Using Algorithms, Rating Scales and Treatment Teams for Depression Management

This retrospective, observational report describes an innovative quality improvement process, Phase-based Care (PBC), that eliminated wait times and achieved positive clinical outcomes in a community mental health center's (CMHC) mood disorder clinic without adding staff. PBC accomplishes this by eliminating the ingrained cultural practice of routinely scheduling stable patients at rote intervals of 1-3 months, regardless of clinical need or medical necessity. Based on four organizational transformations and using mathematical algorithms developed for this process, PBC re-allocates therapy and medical resources away from routinely scheduled appointments and front-loads those resources to patients in an acute phase of illness. To maintain wellness for patients in recovery, lower frequency and intensity approaches are used. This report describes the development of the PBC methodology focusing on the Rapid Recovery Clinic (RRC) comprised of 182 patients with a primary diagnosis of a mood disorder, the largest of the 14 PBC clinics created. Over an 18-month period, wait times were reduced from several months to less than one week and recovery rates, meaning no longer in an acute phase, were 63% and 78% at weeks 6 and 12, respectively for patients who engaged in the program.

Enhancing Conceptual Clarity regarding the Construct of Moral Injury

BACKGROUND

The construct of "moral injury" is used widely in the research literature and media to broadly describe the impact of events involving perceived violations of one's sense of right and wrong (herein referred to as "potentially morally injurious events" [PMIEs]).

SUMMARY

In this theoretical review, we provided a brief overview of the "moral injury" construct and its limitations including the lack of consensus-drawn boundaries and operational definitions to guide hypothesis-driven research. We discussed whether this construct can be reliably distinguished from established psychiatric diagnoses and psychological constructs and the inherent challenges in separating or classifying the impact of high-magnitude stressful life events that likely form the majority of PMIEs. Assessments that purportedly measure "moral injury" are reviewed and limitations are discussed such as shared measurement variance with established psychological instruments.

KEY MESSAGES

We identified conceptual strategies for investigating behavioral and neurobiological features of PMIEs that could be used to inform the field of traumatic stress. We concluded that the construct of "moral injury" may provide an interpretive framework for positing why someone may be beset by guilt, shame, and/or rage whereas existing psychiatric diagnoses such as post-traumatic stress disorder and depression provide comprehensive descriptions regarding what someone might experience following extremely stressful events. We proposed directions to better clarify the boundaries of "moral injury" versus established psychiatric categories that could be used to enhance the conceptualization and assessment of this construct.

Spanish validation of the Empirically Developed Clinical Staging Model (EmDe-5) for patients with bipolar disorder

INTRODUCTION

Bipolar disorder (BD) has been reconceptualised as a progressive disorder that develops from mild to severe presentations. An empirical staging model - the Empirically Developed Clinical Staging Model for BD (EmDe-5) - was developed in a previous study. This study aims to further validate that model using a larger and more representative Spanish sample.

MATERIAL AND METHODS

183 BD outpatients were recruited at 11 sites in Spain. Assessment included clinical characteristics of the BD (number of hospitalisations, number of suicide attempts, comorbid personality disorders), physical health (BMI, metabolic syndrome, number of physical illnesses), cognition (SCIP), functioning (permanently disabled due to BD, FAST), and quality of life (SF-36). The CGI-S, VAS-S, and psychopharmacological treatment pattern were used as external validators.

RESULTS

Ten patients (51.5%) were classified as stage 1, 33 (18%) as stage 2, 93 (508%) as stage 3, 37 (202%) as stage 4, and 10 (55%) as stage 5. All profilers, other than number of suicide attempts (p=0.311) and comorbid personality disorder (p=0.061), exhibited worse scores from stage 1 to 5. As expected, VAS-S and CGI-S scores were worse in the later stages. Regarding treatment, early stages (1-2) were associated with the use of one to three drugs while late stages (4-5) were associated with four or more drugs (p=0.002).

CONCLUSIONS

We confirm the EmDe-5 staging model's construct validity. The ease of obtaining the profilers, together with the operational criteria provided to quantify them, will facilitate the use of the EmDe-5 staging model in daily clinical practice.

Selective Serotonin Reuptake Inhibitor and Serotonin-Noradrenaline Reuptake Inhibitor Withdrawal Changes DSM Presentation of Mental Disorders: Results from the Diagnostic Clinical Interview for Drug Withdrawal

INTRODUCTION

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) may cause withdrawal at dose decrease, discontinuation, or switch. Current diagnostic methods (e.g., DSM) do not take such phenomenon into account. Using a new nosographic classification of withdrawal syndromes due to SSRI/SNRI decrease or discontinuation [by Psychother Psychosom. 2015;84(2):63-71], we explored whether DSM is adequate to identify DSM disorders when withdrawal occurs.

METHODS

Seventy-five self-referred patients with a diagnosis of withdrawal syndrome due to discontinuation of SSRI/SNRI, diagnosed via the Diagnostic Clinical Interview for Drug Withdrawal 1 - New Symptoms of Selective Serotonin Reuptake Inhibitors or Serotonin-Norepinephrine Reuptake Inhibitors (DID-W1), and at least one DSM-5 diagnosis were analyzed.

RESULTS

In 58 cases (77.3%), the DSM-5 diagnosis of current mental disorder was not confirmed when the DID-W1 diagnosis of current withdrawal syndrome was established. In 13 cases (17.3%), the DSM-5 diagnosis of past mental disorder was not confirmed when criteria for DID-W1 diagnosis of lifetime withdrawal syndrome were met. In 3 patients (4%), the DSM-5 diagnoses of current and past mental disorders were not confirmed when the DID-W1 diagnoses of current and lifetime withdrawal syndromes were taken into account. The DSM-5 diagnoses most frequently mis-formulated were current panic disorder (50.7%, n = 38) and past major depressive episode (18.7%, n = 14).

CONCLUSION

DSM needs to be complemented by clinimetric tools, such as the DID-W1, to detect withdrawal syndromes induced by SSRI/SNRI discontinuation, decrease, or switch, following long-term use.

Applying a clinical staging model in patients affected by schizophrenia spectrum disorder

Background

Clinical staging, already widespread in medicine, represents a new frontier in psychiatry. Our goal was to convert the existing theoretical staging model for schizophrenia into a feasible tool to have a timely assessment of patients' health status applicable in any psychiatric facility.

Methods

We assessed the empirical soundness of a staging model for schizophrenia spectrum disorders (SSDs), primarily centered on their current status. This model delineated six sequential stages (1, 2A, 2B, 3A, 3B, and 4) based on factors like symptom recurrence, persistence, and progression, including functional decline. Our analysis involved data from 137 individuals affected by SSDs. We examined 22 baseline variables, 23 construct-related variables, and 31 potentially modifiable clinical variables.

Results

The latter stages demonstrated significantly poorer outcomes compared to the early stages across various measures, indicating medium to large effect sizes and a dose-response pattern. This pattern confirmed the validity of the model. Notably, stages 2 and 3A exhibited pronounced differences in comparison to other stages, although variables from each validation category also distinguished between consecutive stages, particularly 3A and beyond.

Conclusion

Baseline predictors, such as familial predisposition to schizophrenia, neurodevelopmental impairment, childhood adversities, treatment delay, negative symptoms, neurological impairment, and inadequate early response to treatment, independently largely explained the staging variance. The clinical staging model, grounded in the extended course of psychosis, exhibited sound validity and feasibility, even without the use of biological or neuroimaging markers, which could greatly improve the sensitivity of the model. These findings provide insights into stage indicators and predictors of clinical stages from the onset of psychosis.

Omics approaches open new horizons in major depressive disorder: from biomarkers to precision medicine

Major depressive disorder (MDD) is a recurrent episodic mood disorder that represents the third leading cause of disability worldwide. In MDD, several factors can simultaneously contribute to its development, which complicates its diagnosis. According to practical guidelines, antidepressants are the first-line treatment for moderate to severe major depressive episodes. Traditional treatment strategies often follow a one-size-fits-all approach, resulting in suboptimal outcomes for many patients who fail to experience a response or recovery and develop the so-called "therapy-resistant depression". The high biological and clinical inter-variability within patients and the lack of robust biomarkers hinder the finding of specific therapeutic targets, contributing to the high treatment failure rates. In this frame, precision medicine, a paradigm that tailors medical interventions to individual characteristics, would help allocate the most adequate and effective treatment for each patient while minimizing its side effects. In particular, multi-omic studies may unveil the intricate interplays between genetic predispositions and exposure to environmental factors through the study of epigenomics, transcriptomics, proteomics, metabolomics, gut microbiomics, and immunomics. The integration of the flow of multi-omic information into molecular pathways may produce better outcomes than the current psychopharmacological approach, which targets singular molecular factors mainly related to the monoamine systems, disregarding the complex network of our organism. The concept of system biomedicine involves the integration and analysis of enormous datasets generated with different technologies, creating a "patient fingerprint", which defines the underlying biological mechanisms of every patient. This review, centered on precision medicine, explores the integration of multi-omic approaches as clinical tools for prediction in MDD at a single-patient level. It investigates how combining the existing technologies used for diagnostic, stratification, prognostic, and treatment-response biomarkers discovery with artificial intelligence can improve the assessment and treatment of MDD.

Characterising illness stages and recovery trajectories of eating disorders in young people via remote measurement technology (STORY): a multi-centre prospective cohort study protocol

BACKGROUND

Eating disorders (EDs) are serious, often chronic, conditions associated with pronounced morbidity, mortality, and dysfunction increasingly affecting young people worldwide. Illness progression, stages and recovery trajectories of EDs are still poorly characterised. The STORY study dynamically and longitudinally assesses young people with different EDs (restricting; bingeing/bulimic presentations) and illness durations (earlier; later stages) compared to healthy controls. Remote measurement technology (RMT) with active and passive sensing is used to advance understanding of the heterogeneity of earlier and more progressed clinical presentations and predictors of recovery or relapse.

METHODS

STORY follows 720 young people aged 16-25 with EDs and 120 healthy controls for 12 months. Online self-report questionnaires regularly assess ED symptoms, psychiatric comorbidities, quality of life, and socioeconomic environment. Additional ongoing monitoring using multi-parametric RMT via smartphones and wearable smart rings ('Ōura ring') unobtrusively measures individuals' daily behaviour and physiology (e.g., Bluetooth connections, sleep, autonomic arousal). A subgroup of participants completes additional in-person cognitive and neuroimaging assessments at study-baseline and after 12 months.

DISCUSSION

By leveraging these large-scale longitudinal data from participants across ED diagnoses and illness durations, the STORY study seeks to elucidate potential biopsychosocial predictors of outcome, their interplay with developmental and socioemotional changes, and barriers and facilitators of recovery. STORY holds the promise of providing actionable findings that can be translated into clinical practice by informing the development of both early intervention and personalised treatment that is tailored to illness stage and individual circumstances, ultimately disrupting the long-term burden of EDs on individuals and their families.

Staging models in eating disorders: A systematic scoping review of the literature

Eating Disorders (ED) are characterized by low remission rates, treatment drop-out, and residual symptoms. To improve assessment and treatment of ED, the staging approach has been proposed. This systematic scoping review is aimed at mapping the existing staging models that explicitly propose stages of the progression of ED. A systematic search of PubMed, PsycINFO, Scopus was conducted with the terms staging, anorexia nervosa, bulimia nervosa, binge-eating disorders, eating disorders. Eleven studies met inclusion criteria presenting nine ED staging models, mostly for anorexia nervosa. Three were empirically tested, one of which was through an objective measure specifically developed to differentiate between stages. Most staging models featured early stages in which the exacerbation of EDs unfolds and acute phases are followed by chronic stages. Intermediate stages were not limited to acute stages, but also residual phases, remission, relapse, and recovery. The criteria for stage differentiation encompassed behavioral, psychological, cognitive, and physical features including body mass index and illness duration. One study recommended stage-oriented interventions. The current review underscores the need to empirically test the available staging models and to develop and test new proposals of staging models for other ED populations. The inclusion of criteria based on medical features and biomarkers is recommended. Staging models can potentially guide assessment and interventions in daily clinical settings.

An empirical analysis of structural neuroimaging profiles in a staging model of depression

We examine structural brain characteristics across three diagnostic categories: at risk for serious mental illness; first-presenting episode and recurrent major depressive disorder (MDD). We investigate whether the three diagnostic groups display a stepwise pattern of brain changes in the cortico-limbic regions. Integrated clinical and neuroimaging data from three large Canadian studies were pooled (total n = 622 participants, aged 12-66 years). Four clinical profiles were used in the classification of a clinical staging model: healthy comparison individuals with no history of depression (HC, n = 240), individuals at high risk for serious mental illness due to the presence of subclinical symptoms (SC, n = 80), first-episode depression (FD, n = 82), and participants with recurrent MDD in a current major depressive episode (RD, n = 220). Whole-brain volumetric measurements were extracted with FreeSurfer 7.1 and examined using three different types of analyses. Hippocampal volume decrease and cortico-limbic thinning were the most informative features for the RD vs HC comparisons. FD vs HC revealed that FD participants were characterized by a focal decrease in cortical thickness and global enlargement in amygdala volumes. Greater total amygdala volumes were significantly associated with earlier onset of illness in the FD but not the RD group. We did not confirm the construct validity of a tested clinical staging model, as a differential pattern of brain alterations was identified across the three diagnostic groups that did not parallel a stepwise clinical staging approach. The pathological processes during early stages of the illness may fundamentally differ from those that occur at later stages with clinical progression.

PsiOvi Staging Model for Schizophrenia (PsiOvi SMS): A New Internet Tool for Staging Patients with Schizophrenia

BACKGROUND

One of the challenges of psychiatry is the staging of patients, especially those with severe mental disorders. Therefore, we aim to develop an empirical staging model for schizophrenia.

METHODS

Data were obtained from 212 stable outpatients with schizophrenia: demographic, clinical, psychometric (PANSS, CAINS, CDSS, OSQ, CGI-S, PSP, MATRICS), inflammatory peripheral blood markers (C-reactive protein, interleukins-1RA and 6, and platelet/lymphocyte [PLR], neutrophil/lymphocyte [NLR], and monocyte/lymphocyte [MLR] ratios). We used machine learning techniques to develop the model (genetic algorithms, support vector machines) and applied a fitness function to measure the model's accuracy (% agreement between patient classification of our model and the CGI-S).

RESULTS

Our model includes 12 variables from 5 dimensions: 1) psychopathology: positive, negative, depressive, general psychopathology symptoms; 2) clinical features: number of hospitalizations; 3) cognition: processing speed, visual learning, social cognition; 4) biomarkers: PLR, NLR, MLR; and 5) functioning: PSP total score. Accuracy was 62% (SD = 5.3), and sensitivity values were appropriate for mild, moderate, and marked severity (from 0.62106 to 0.6728).

DISCUSSION

We present a multidimensional, accessible, and easy-to-apply model that goes beyond simply categorizing patients according to CGI-S score. It provides clinicians with a multifaceted patient profile that facilitates the design of personalized intervention plans.

Long-term trajectories of clinical staging in first-episode psychosis and their associated cognitive outcome: A 21-year follow-up study

Cognitive deficits are already present before psychosis onset but are a key feature of first-episode psychosis (FEP). The objective of this study was to investigate the cognitive outcomes of a cohort of FEP patients who were diagnosed using the clinical staging approach and were followed for up to 21 years. We analyzed data from 173 participants with first-admission psychosis who were followed-up for a mean of 20.9 years. The clinical staging assessment was adapted from the clinical staging framework developed by McGorry et al.1 Cognitive assessment was performed using the MATRICS Consensus Cognitive Battery (MMCB) at the end of follow-up. FEP patients who were longitudinally diagnosed in the lowest clinical stages (stages 2A and 2B) showed better performance in attention, processing speed, and MCCB overall composite score than those in the highest clinical stages (stages 4A and 4B). There was a significant linear trend association between worsening of all MCCB cognitive functions and MCCB overall composite score and progression in clinical staging. Furthermore, the interval between two and five years of follow-up appears to be associated with deficits in processing speed as a cognitive marker. Our results support the validation of the clinical staging model over a long-term course of FEP based on neuropsychological performance. A decline in some cognitive functions, such as processing speed, may facilitate the transition of patients to an advanced stage during the critical period of first-episode psychosis.

Emerging psychopathology and clinical staging in adolescent offspring of parents with bipolar disorder or schizophrenia-A longitudinal study

OBJECTIVES

Offspring of parents with bipolar disorder (BDo) and schizophrenia (SZo) are at increased risk for these disorders and general psychopathology. Little is known about their (dis)similarities in risk and developmental trajectories during adolescence. A clinical staging approach may help define the developmental course of illness.

METHODS

The Dutch Bipolar and Schizophrenia Offspring Study is a unique cross-disorder and prospective cohort study, established in 2010. In total, 208 offspring (58 SZo, 94 BDo, and 56 control offspring [Co]) and their parents participated. Offspring were 13.2 years (SD = 2.5; range: 8-18 years) at baseline and 17.1 years (SD = 2.7) at follow-up (88.5% retention rate). Psychopathology was assessed using the Kiddie Schedule for Affective Disorders and Schizophrenia for School Age Children Present and Lifetime Version, and Achenbach System of Empirically Based Assessment parent-, self- and teacher-reports. Groups were compared on (1) the presence of categorical psychopathology, (2) timing and development of psychopathology using a clinical staging perspective, and (3) dimensional psychopathology using a multi-informant approach.

RESULTS

SZo and BDo showed more categorical psychopathology and (sub)clinical symptoms, as compared to Co. SZo have, compared to BDo, an increased risk for developmental disorders, a younger age of onset, and more (sub)clinical symptoms of the mood and behavioral spectrum as reported by multiple informants.

CONCLUSIONS

Our study shows that the phenotypical risk profile overlaps between SZo and BDo, although an earlier onset of developmental psychopathology was found specifically in SZo, suggesting of a potentially different ethiopathophysiology. Longer follow-up and future studies are needed.

Well-Being Therapy for Depression

Well-being therapy (WBT) is a short-term psychotherapeutic strategy, based on the technique of self-observation via the use of a structured diary and the guide of a therapist, with the goal of increasing psychological well-being, thus reaching euthymia and a balance among psychic forces. WBT showed to be suitable for application in residual symptoms of unipolar and bipolar depression, since the sequential combination with cognitive-behavioural therapy (CBT) led to a decrease in the relapse rate of recurrent depression. WBT also showed clinical utility in the treatment of cyclothymia, which represents one of the stages of bipolar disorder. Further, WBT seems to have efficacy in treatment-resistant depression and in case of withdrawal syndromes (in particular the so-called persistent post-withdrawal disorder) following antidepressant decrease, switch or discontinuation. In brief, WBT is a rather new but promising therapeutic strategy in the management of unipolar and bipolar depression. This chapter offers an overview of WBT possible applications.

Clinical staging across eating disorders: a scoping review protocol

INTRODUCTION

Clinical staging models in psychiatry assert that there are earlier, less severe or more malleable forms of illness that are distinguishable from later, more chronic forms of illness, and that these stages may have different prognostic and treatment implications. Previous reviews on clinical staging in eating disorders (EDs) suggest a staging heuristic could be useful for anorexia nervosa, but less research is available on how this applies to other EDs. An up-to-date review is required to synthesise new and heterogenous avenues of research. This scoping review aims to explore the extent and types of evidence in relation to illness staging for EDs and how these concepts are associated with treatment response and outcomes.

METHODS AND ANALYSIS

This protocol was developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol extension for Scoping Reviews checklist and the Joanna Briggs Institute Reviewer's Manual. We will consider any documents providing evidence for clinical staging such as those which describe full or partial staging models, for all EDs, across various domains of assessment and functioning. Participants will include clinical or non-clinical population samples with full-syndrome EDs or disordered eating behaviour. PubMed, PsycINFO, MEDLINE and Web of Science databases will be systematically searched for relevant literature. Two authors will export documents and screen titles, abstracts and full texts. Data will be extracted into a charting form drafted by the authors. A narrative summary of the documents will be conducted in line with the study aims. Finally, clinical and research recommendations will be outlined.

ETHICS AND DISSEMINATION

Ethical approval will not be required to synthesise published and unpublished literature. The study will be published in a peer-reviewed journal and shared at conferences, via social media, and in other communications.

Correlates of severity in a clinical staging model of schizophrenia: a cross-sectional study among 158 subjects

BACKGROUND

Clinical staging has been widely used to predict and optimize the treatment of medical disorders. Different models have been proposed to map the development, progression, and extension of psychiatric disorders over time, mainly for schizophrenia. The primary objective of this study was to classify patients with psychosis according to the McGorry staging model and compare factors between the different stages.

METHODS

This was a cross-sectional study, collecting data from 158 patients hospitalized for schizophrenia/psychosis. The survey included the Mini International Neuropsychiatric Interview (MINI), Positive and Negative Symptom Scale (PANSS), Montgomery-Asberg Depression Rating Scale (MADRS), Yong Mania Rating Scale (YMRS), Clinical Global Impression (CGI) scale, and the McGorry staging model.

RESULTS

Patients have been classified into three clinical stages: relapse of psychotic disorder (43%), multiple relapses (47.5%), and persistent and severe illness (9.5%). A higher mean duration of hospitalization, psychotic symptoms (PANSS total scale and subscales), chlorpromazine equivalent dose, and number of antipsychotic treatments were found among participants in Stage 4 as compared to the other groups. However, a significantly higher mean GAF scale was found among participants in stage 3b as compared to the other groups.

CONCLUSION

Each stage in the McGorry staging model of schizophrenia is associated with well-defined clinical presentations, which help decide the appropriate treatment. Using such models in psychiatry can improve the diagnostic process and potential therapeutic interventions for patients suffering from mental disorders.

The diagnosis that should speak its name: why it is ethically right to diagnose and treat personality disorder during adolescence

Although national guidelines explicitly state that personality disorder can be diagnosed and treated in young people aged 12 to 18 years (adolescents), most clinicians remain hesitant. This creates a gap between science and practice, which we argue is largely motivated by moral reasons and, therefore, is best challenged by ethical arguments. We provide seven arguments in support of the notion that it is ethically right to diagnose and treat personality disorder when it occurs in adolescents. Central to these arguments is the scientific evidence that features of personality disorder are among the best predictors of a complex cluster of psychopathology leading to impairments in many areas of current and future mental, social and vocational functioning. We argue that intervention during adolescence and young adulthood is not only humane, but also critical for efforts to avert the longstanding psychosocial and health problems that seem refractory to treatment in adults with personality disorder. Moreover, we argue that regular services are often inadequately equipped to meet the needs of young people with personality disorder and that the common 'stepped-care' approach should be replaced by a 'staged-care' approach. Finally, we argue that early detection and intervention might have anti-stigmatizing effects, similar to other areas of healthcare in which stigmatizing labels have changed meaning when the conditions to which they refer have become more amenable to treatment.

A clinical staging model of psychotic disorders based on a long-term follow-up of first-admission psychosis: A validation study

We examined the empirical validity of a staging model of psychotic disorders primarily based on their long-term course. The model distinguished 6 consecutive stages (2A, 2B, 3A, 3B, 4A, 4B) based on symptom recurrence, persistence and progression, such as functional decline. We analyzed data from 243 participants with first-admission psychosis who were followed-up for a mean of 20.9 years and assessed for 22 baseline variables, 23 construct-related variables and 31 outcome variables. Later stages scored significantly poorer than early stages on most validators by showing generally medium to large effect sizes and a dose-response pattern, thus confirming the validity of the model. For each set of validators, differences between consecutive stages were especially evident for stages 2 and 3A, although many variables from each validation realm also differentiated between the consecutive stages 3A and above. Baseline predictors including familial load of schizophrenia, neurodevelopmental impairment, childhood adversity, treatment delay, negative symptoms, neurological impairment and poor early response to treatment, independently accounted for 49.9% of the variance of staging. A staging model of psychosis based primarily on its long-term course has sound construct, outcome and predictive validity, which may inform about stage indicators and predictors of clinical stages from psychosis onset.

Empirically driven transdiagnostic stages in the development of mood, anxiety and psychotic symptoms in a cohort of youth followed from birth

Staging models with transdiagnostic validity across mood, psychotic, and anxiety disorders could advance early intervention efforts as well as our understanding of the common underpinnings of such psychopathology. However, there are few well-supported operationalisations for such transdiagnostic models, particularly in community-based samples. We aimed to explore the inter-relationships among mood, psychotic, and anxiety symptom stages, and their common risk factors to develop data-informed transdiagnostic stages. We included participants from the Avon Longitudinal Study of Parents and Children (ALSPAC), a prospective ongoing birth cohort study. We developed operational thresholds for stages of depressive, hypomanic, anxiety, and psychotic symptoms based on the existing literature, refined further by expert consensus. We selected 1b level as the primary stage or outcome of interest. This represents moderate symptoms that are likely to be associated with the onset of the need for clinical mental health care. We used questionnaire and clinic data completed by young people ages 18 and 21 years. We used descriptive methods and network analyses to examine the overlap among Stage 1b psychopathology. We then examined the patterns of relationships between several risk factors and 1b stages using logistic regressions. Among 3269 young people with data available to determine all symptom stages, 64.3% were female and 96% Caucasian. Descriptive and network analyses indicated that 1b level depressive, anxiety, and psychotic symptom stages were inter-related while hypomania was not. Similarly, anxiety, depressive, and psychotic 1b stages were associated with the female sex, more emotional and behavioral difficulties in early adolescence, and life events in late adolescence. Hypomania was not related to any of these risk factors. Given their inter-relationships and similar risk factors, anxiety, psychotic and depressive, symptoms could be combined to form a transdiagnostic stage in this cohort. Such empirical transdiagnostic stages could help with prognostication and indicated prevention in youth mental health.

Biomarkers of neuroprogression and late staging in bipolar disorder: A systematic review

BACKGROUND

Bipolar disorder may undertake a progressive course in a subset of patients, and research efforts have been made to understand the biological basis underlying this process. This systematic review examined the literature available on biological markers associated with illness progression in bipolar disorder.

METHODS

Peer-reviewed articles were assessed using Embase, PsycINFO and PubMed, as well as from external sources. After initial screening, a total of 871 citations from databases and other sources were identified. Participants with a diagnosis of bipolar disorder were included in our systematic review; however, studies with participants younger than 15 or older than 65 were excluded. All studies were assessed using the Newcastle-Ottawa Scale assessment tool, and data pertaining to the results were extracted into tabular form using Google Sheets and Google Documents. The systematic review was registered on PROSPERO international prospective register of systematic reviews (ID Number: CRD42020154305).

RESULTS

A total of 35 studies were included in the systematic review. Increased ventricular size and reduction of grey matter volume were the most common brain changes associated with illness progression in bipolar disorder. Among the several biomarkers evaluated in this systematic review, findings also indicate a role of peripheral inflammatory markers in this process.

DISCUSSION

The studies evaluating the biological basis of the illness progression in bipolar disorder are still scarce and heterogeneous. However, current evidence supports the notion of neuroprogression, the pathophysiological process related to progressive brain changes associated with clinical progression in patients with bipolar disorder. The increase in peripheral inflammatory biomarkers and the neuroanatomical changes in bipolar disorder suggest progressive systemic and structural brain alterations, respectively.

Time trends in mental health indicators in Germany's adult population before and during the COVID-19 pandemic

Background

Times of crisis such as the COVID-19 pandemic are expected to compromise mental health. Despite a large number of studies, evidence on the development of mental health in general populations during the pandemic is inconclusive. One reason may be that representative data spanning the whole pandemic and allowing for comparisons to pre-pandemic data are scarce.

Methods

We analyzed representative data from telephone surveys of Germany's adults. Three mental health indicators were observed in ~1,000 and later up to 3,000 randomly sampled participants monthly until June 2022: symptoms of depression (observed since April 2019, PHQ-2), symptoms of anxiety (GAD-2), and self-rated mental health (latter two observed since March 2021). We produced time series graphs including estimated three-month moving means and proportions of positive screens (PHQ/GAD-2 score ≥ 3) and reports of very good/excellent mental health, as well as smoothing curves. We also compared time periods between years. Analyses were stratified by sex, age, and level of education.

Results

While mean depressive symptom scores declined from the first wave of the pandemic to summer 2020, they increased from October 2020 and remained consistently elevated throughout 2021 with another increase between 2021 and 2022. Correspondingly, the proportion of positive screens first decreased from 11.1% in spring/summer 2019 to 9.3% in the same period in 2020 and then rose to 13.1% in 2021 and to 16.9% in 2022. While depressive symptoms increased in all subgroups at different times, developments among women (earlier increase), the youngest (notable increase in 2021) and eldest adults, as well as the high level of education group (both latter groups: early, continuous increases) stand out. However, the social gradient in symptom levels between education groups remained unchanged. Symptoms of anxiety also increased while self-rated mental health decreased between 2021 and 2022.

Conclusion

Elevated symptom levels and reduced self-rated mental health at the end of our observation period in June 2022 call for further continuous mental health surveillance. Mental healthcare needs of the population should be monitored closely. Findings should serve to inform policymakers and clinicians of ongoing dynamics to guide health promotion, prevention, and care.

Intervention Programs for First-Episode Psychosis: A Scoping Review Protocol

Early intervention programs for first-episode psychosis aim to intervene in the early stages of the disease. They are essential to prevent and delay the progression of the illness to a more advanced stage, but information about their characteristics is not systematized. The scoping review considered all studies of first-episode psychosis intervention programs, regardless of their context (hospital or community), and explored their characteristics. The scoping review was developed according to the Joanna Briggs Institute methodology and PRISMA-ScR guidelines. The PCC mnemonic (population, concept, and context) addressed research questions, the inclusion and exclusion criteria, and the search strategy. The scoping review sought to identify the literature that meets the predefined inclusion criteria. The research was conducted in the following databases: Web of Science Core Collection, MEDLINE, CINAHL Complete and PsycINFO, Scopus, Cochrane Library, and JBI Evidence Synthesis. The search for unpublished studies included OpenGrey (a European repository) and MedNar. It used sources in English, Portuguese, Spanish, and French. It included quantitative, qualitative, and multi-method/mixed methods studies. It also considered gray or unpublished literature. After removing duplicates, two independent reviewers extracted the relevant information after selecting the articles. If there were disagreements, a third reviewer was used. The researchers have developed a tool based on the JBI model that will allow them to extract the relevant information for the review. The results are presented schematically in narratives and tables. This scoping review maps first-episode psychosis intervention programs by identifying their characteristics, participants, and specific implementation contexts and allows researchers to create multicomponent programs tailored to different contexts.

The update of self-identity: Importance of assessing autobiographical memory in major depressive disorder

Major depressive disorder is a leading global cause of disability. There is a growing interest for memory in mood disorders since it might constitute an original tool for prevention, diagnosis, and treatment. MDD is associated with impaired autobiographical memory characterized by a tendency to overgeneral memory, rather than vivid episodic self-defining memory, which is mandatory for problem-solving and projection in the future. This memory bias is maintained by three mechanisms: ruminations, avoidance, and impaired executive control. If we adopt a broader and comprehensive perspective, we can hypothesize that all those alterations have the potential to impair self-identity updating. We posit that this update requires a double referencing process: (1) to internalized self-representation and (2) to an externalized framework dealing with the representation of the consequence of actions. Diagnostic and therapeutic implications are discussed in the light of this model and the importance of assessing autobiographical memory in MDD is highlighted. This article is categorized under: Psychology > Memory Psychology > Brain Function and Dysfunction Neuroscience > Clinical.

Clinical utility of demoralization: A systematic review of the literature

Demoralization is a complex clinical phenomenon which has raised a growing interest in clinical and research realms. The present systematic review of the literature aimed at (1) updating on demoralization prevalence in different populations, (2) identifying the instruments more largely used to assess demoralization, and (3) verifying whether new tools of assessment have been proposed. PubMed and Web of Science were searched from inception to April 2022. Search terms were: demoralization/demoralized/demoralizing/demoralised/demoralising. PRISMA guidelines were followed. GRADE rating system was used. A total of 188 papers were included. Demoralization appeared to be a distinctive psychological state common in medical, psychiatric, and non-clinical settings, thus not limited to life-threatening diseases. Diagnostic Criteria for Psychosomatic Research (DCPR) and Demoralization Scale (DS) are the most commonly used tools to assess it. DCPR allow to diagnose demoralization as a manifestation of dealing with chronic stress. DS captures dimensionally a psychological distress related to end of life. Demoralization is associated with clinical features encompassing allostatic overload, quality of life, wellbeing/euthymia. Implications on health outcomes and treatment are discussed. Demoralization warrants careful consideration in clinical contexts through valid assessment procedures. DCPR are recommended to diagnose it, DS can be helpful to capture clinical details.

The efficacy and safety of cariprazine in the early and late stage of schizophrenia: a post hoc analysis of three randomized, placebo-controlled trials

BACKGROUND

The aim of the post hoc analysis was to better understand the efficacy and safety of cariprazine in patients with schizophrenia for less than 5 years (early stage) and for more than 15 years (late stage).

METHODS

Data from three phase II/III randomized, double-blind, placebo-controlled trials with similar design in patients with acute exacerbation of schizophrenia were pooled and patients with early and late stage of schizophrenia were determined. A mixed-effects model for repeated measures approach was applied and least square (LS) mean changes from baseline to week 6 on the Positive and Negative Syndrome Scale (PANSS) total and factor scores were reported. Descriptive statistics were used for safety analyses including treatment emergent adverse events (TEAEs) and discontinuation rates.

RESULTS

Overall, 460 patients were identified as being in the early and 414 in the late stage of schizophrenia. The pooled analysis evaluating mean change from baseline to week 6 in the PANSS total score indicated statistically significant difference between cariprazine and placebo in favor of cariprazine in both the early (LS mean difference [LSMD] -7.5 P < .001) and late stage (LSMD -6.7, P < .01) subpopulation. Early stage patients experienced similar amount of TEAEs (CAR 67.3%, PBO 54.1%) as patients in the late stage (CAR 69.6%, PBO 65.6%).

CONCLUSION

In conclusion, cariprazine, a potent D₃-D₂ partial agonist has been found to be safe and effective in the treatment of early and late stage schizophrenia.

Toward staging differentiation for posttraumatic stress disorder treatment

OBJECTIVES

Several medical and psychiatric disorders have stage-based treatment decision-making methods. However, international treatment guidelines for posttraumatic stress disorder (PTSD) fail to give specific treatment recommendations based on chronicity or stage of the disorder. There is convincing evidence of a finite range of PTSD symptom trajectories, implying that different phenotypes of the disorder can be distinguished, which are highly relevant for a staging typology of PTSD.

METHODS

State-of-the-art review building on prior work on staging models in other disorders as a mapping tool to identify and synthesize toward PTSD.

RESULTS

We propose a four-stage model of PTSD ranging from stage 0: trauma-exposed asymptomatic but at risk to stage 4: severe unremitting illness of increasing chronicity. We favor a symptom description in various chronological characteristics based on neurobiological markers, information processing systems, stress reactivity, and consciousness dimensions. We also advocate for a separate phenomenology of treatment resistance since this can yield treatment recommendations.

CONCLUSION

A staging perspective in the field of PTSD is highly needed. This can facilitate the selection of interventions that are proportionate to patients' current needs and risk of illness progression and can also contribute to an efficient framework to organize biomarker data and guide service delivery. Therefore, we propose that a neurobiologically driven trajectory-based typology of PTSD can help deduct several treatment recommendations leading to a more personalized and refined grid to strategize, plan and evaluate treatment interventions.

Transdiagnostic Clinical Staging for Childhood Mental Health: An Adjunctive Tool for Classifying Internalizing and Externalizing Syndromes that Emerge in Children Aged 5-11 Years

Clinical staging is now recognized as a key tool for facilitating innovation in personalized and preventative mental health care. It places a strong emphasis on the salience of indicated prevention, early intervention, and secondary prevention of major mental disorders. By contrast to established models for major mood and psychotic syndromes that emerge after puberty, developments in clinical staging for childhood-onset disorders lags significantly behind. In this article, criteria for a transdiagnostic staging model for those internalizing and externalizing disorders that emerge in childhood is presented. This sits alongside three putative pathophysiological profiles (developmental, circadian, and anxious-arousal) that may underpin these common illness trajectories. Given available evidence, we argue that it is now timely to develop a transdiagnostic staging model for childhood-onset syndromes. It is further argued that a transdiagnostic staging model has the potential to capture more precisely the dimensional, fluctuating developmental patterns of illness progression of childhood psychopathology. Given potential improvements in modelling etiological processes, and delivering more personalized interventions, transdiagnostic clinical staging for childhood holds much promise for assisting to improve outcomes. We finish by presenting an agenda for research in developments of transdiagnostic clinical staging for childhood mental health.

Influencing Factors in MOOCs Adoption in Higher Education: A Meta-Analytic Path Analysis

(1) Background: Due to the rapid growth of Massive Online Open Courses (MOOCs), higher educational institutions across the world are investing heavily in MOOCs to support their traditional teaching, their students’ learning experience, and their performance. However, the success of MOOCs highly depends on several factors that influence their success in higher education. Prior studies have attempted to investigate and predict user acceptance of MOOCs in higher education by using a variety of theoretical viewpoints. Nonetheless, these studies have yielded conflicting findings and are inconclusive. (2) Purpose: This study aims to develop a model that integrates the Theory of Planned Behavior (TPB), the Unified Theory of Acceptance and Use of Technology (UTAUT), as well as the Task-Technology Fit (TTF) to explore the factors that influence the acceptance and use of MOOCs in higher education institutions, while synthesizing previous empirical findings in the field. (3) Methods: The model was tested using Meta-analytic Structural Equation Modelling (MASEM) based on the data gathered from 43 studies (k = 45 samples, n = 16,774). (4) Results: Effort expectancy (EE), attitude (ATT), performance expectancy (PE), and TTF—determined by several task and technology characteristics—were identified as the direct predictors of behavioral intention (BI) to continue using MOOCs. (5) Conclusions: This model provides a cohesive view of MOOCs’ acceptance in higher educational institutions, and it helps to identify potential research opportunities in this area. (6) Implications: Results from MASEM offer managerial guidance for the effective implementation of MOOCs and provide directions for further research, to augment current knowledge of MOOCs’ adoption, by higher education institutions.

Staging of unipolar depression: systematic review and discussion of clinical implications

Staging has been increasingly used in unipolar depression since its introduction in the nineties. Several models are available, but their differential features and implications are not completely clear. We systematically reviewed: (a) staging models of longitudinal development of unipolar depression; (b) staging models of treatment-resistant unipolar depression; (c) their applications. MEDLINE, PsycINFO, EMBASE, and Web of Science were examined according to PRISMA guidelines from inception to December 2021. Search terms were: 'stage/staging', combined using the Boolean 'AND' operator with 'psychiatric disorder/mental disorder/depressive/mood disorder'. A total of 169 studies were identified for inclusion: 18 described staging models or applications, 151 described treatment-resistant staging models or applications. Staging models of longitudinal development were found to play a key role in formulating sequential treatment, with particular reference to the use of psychotherapy after pharmacotherapy. Staging methods based on treatment resistance played a crucial role in setting entry criteria for randomized clinical trials and neurobiological investigations. Staging is part of clinimetrics, the science of clinical measurements, and its role can be enhanced by its association with other clinimetric strategies, such as repeated assessments, organization of problematic areas, and evaluation of phenomena that may affect responsiveness. In research, it may allow to identify more homogeneous populations in terms of treatment history that may diminish the likelihood of spurious results in comparisons. In clinical practice, the use of staging in a clinimetric perspective allows clinicians to make full use of the information that is available for an individual patient at a specific time.

Prolonged grief disorder in DSM-5-TR: Early predictors and longitudinal measurement invariance

OBJECTIVE

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision includes prolonged grief disorder as a novel disorder. Prolonged grief disorder can be diagnosed when acute grief stays distressing and disabling, beyond 12 months following bereavement. Evidence indicates that elevated prolonged grief disorder symptoms in the first year of bereavement predict pervasive grief later in time; targeting early elevated grief may potentially prevent symptoms getting chronic. There is limited knowledge about the characteristics of people in the first year of bereavement who have an elevated chance of developing full prolonged grief disorder beyond the 12-month time point. This study examined these characteristics.

METHODS

We used self-reported data from 306 adults who all completed questions on socio-demographic and loss-related characteristics plus a measure of prolonged grief disorder within the first year of bereavement (Wave 1; time since loss: M = 4.97, SD = 3.13 months) and again 1 year later (Wave 2; time since loss: M = 17.84, SD = 3.38 months). We examined the prevalence rates of probable prolonged grief disorder (Wave 2), measurement invariance of prolonged grief disorder symptoms between waves, and associations of socio-demographic and loss-related variables, and Wave 1 prolonged grief disorder with probable prolonged grief disorder at Wave 2.

RESULTS

Regarding prevalence, 10.1% (n = 31) met criteria for probable prolonged grief disorder (Wave 2). Multigroup confirmatory factor analysis supported longitudinal measurement invariance of prolonged grief disorder symptoms. People meeting criteria at Wave 1 (except the time criterion) had a significantly increased risk of meeting criteria at Wave 2. Variables best predicting probable prolonged grief disorder at Wave 2 were prolonged grief disorder at Wave 1, lower education, loss of a child and loss to unnatural/violent causes (sensitivity = 56.67%, specificity = 98.12%, 93.92% correct classifications).

CONCLUSION

People meeting criteria for prolonged grief disorder (except the time criterion) before the first anniversary of the death are at risk of full-blown prolonged grief disorder beyond this time point, particularly those who have lower education, confronted the death of a child and confronted unnatural/violent loss. Findings may inform advances in preventive bereavement care.

Is it possible to stage schizophrenia? A systematic review

INTRODUCTION

A staging model is a clinical tool used to define the development of a disease over time. In schizophrenia, authors have proposed different theoretical staging models of increasing complexity. Therefore, the aims of our study were to provide an updated and critical view of the proposed clinical staging models for schizophrenia and to review the empirical data that support them.

METHODS

Systematic literature review following PRISMA guidelines. From the PubMed database and backward reference search, a total of 141 records were retrieved, but only 20 were selected according to the inclusion criteria: (a) available in English; (b) participants with schizophrenia ≥ 18 years; and (c) theoretical and empirical research studies intended to develop, validate, and/or improve staging models of schizophrenia.

RESULTS

Different clinical staging models for schizophrenia were identified, information about the proposed stages was tabulated and presented in the Results section (Tables 1, 2). Most of which include neuroimaging, functioning, and psychopathology, but only two models add objective biomarkers and none include patient point of view. However, few models have been psychometrically tested or used small samples and thus have been validated only partially. In addition, five studies proposed therapeutic interventions according to the stage of the disorder from a theoretical point of view.

DISCUSSION

In conclusion, it is possible to stage schizophrenia, but the models developed have several limitations. Empirical validation and inclusion of more specific biomarkers and measures of other life areas affected by schizophrenia could help in the development of more valid models.

Treating Insomnia with High Risk of Depression Using Therapist-Guided Digital Cognitive, Behavioral, and Circadian Rhythm Support Interventions to Prevent Worsening of Depressive Symptoms: A Randomized Controlled Trial

INTRODUCTION

The global disease burden of major depressive disorder urgently requires prevention in high-risk individuals, such as recently discovered insomnia subtypes. Previous studies targeting insomnia with fully automated eHealth interventions to prevent depression are inconclusive: dropout was high and likely biased, and depressive symptoms in untreated participants on average improved rather than worsened.

OBJECTIVE

This randomized controlled trial aimed to efficiently prevent the worsening of depressive symptoms by selecting insomnia subtypes at high risk of depression for internet-based circadian rhythm support (CRS), cognitive behavioral therapy for insomnia (CBT-I), or their combination (CBT-I+CRS), with online therapist guidance to promote adherence.

METHODS

Participants with an insomnia disorder subtype conveying an increased risk of depression (n = 132) were randomized to no treatment (NT), CRS, CBT-I, or CBT-I+CRS. The Inventory of Depressive Symptomatology - Self Report (IDS-SR) was self-administered at baseline and at four follow-ups spanning 1 year.

RESULTS

Without treatment, depressive symptoms indeed worsened (d = 0.28, p = 0.041) in high-risk insomnia, but not in a reference group with low-risk insomnia. Therapist-guided CBT-I and CBT-I+CRS reduced IDS-SR ratings across all follow-up assessments (respectively, d = -0.80, p = 0.001; d = -0.95, p < 0.001). Only CBT-I+CRS reduced the 1-year incidence of clinically meaningful worsening (p = 0.002). Dropout during therapist-guided interventions was very low (8%) compared to previous automated interventions (57-62%).

CONCLUSIONS

The findings tentatively suggest that the efficiency of population-wide preventive strategies could benefit from the possibility to select insomnia subtypes at high risk of developing depression for therapist-guided digital CBT-I+CRS. This treatment may provide effective long-term prevention of worsening of depressive symptoms.

TRIAL REGISTRATION

the Netherlands Trial Register (NL7359).

The Clinical Science of Euthymia: A Conceptual Map

Euthymia is a trans-diagnostic construct characterized by lack of mood disturbances; presence of positive affect; balance of psychological well-being dimensions, flexibility, consistency, and resistance to stress. The aim of this critical review is to draw a conceptual map of euthymia. Relationships with other constructs, continuum between euthymia and dysthymia with discomfort as an intermediate area, associations with lifestyle, clinimetric assessment, role of psychotherapeutic interventions, establishment of therapeutic targets, and neurobiological mechanisms are discussed. The model is based on the bipolar nature of well-being dimensions. Euthymia means using allostasis optimally and maintaining a healthy balance that promotes positive aspects of brain and body health through health-promoting behaviors. It may provide a framework for a renewed definition of recovery, for measuring treatment outcome and for targeting interventions, including the sequential administration of therapeutic components. Clinical assessment requires a clinimetric approach encompassing a broad range of aspects, such as allostatic load and lifestyle behaviors, all interacting with each other and contributing to the euthymia/dysthymia balance. Clinimetric indices for assessing euthymia (the Clinical Interview for Euthymia and the Euthymia Scale) and related constructs (the Clinical Interview for Dysthymia and the Semi-Structured Interview for the Diagnostic Criteria for Psychosomatic Research) are presented here. Well-Being Therapy, a psychotherapeutic strategy specifically aimed at pursuing euthymia, relies on self-observation of well-being episodes using a structured diary as a distinct therapeutic ingredient. The clinical science of euthymia may unravel innovative approaches to assessment and treatment of psychiatric and medical disorders, according to a unitary conceptual framework.

Application of a staging model in patients with obsessive-compulsive disorder: cross-sectional and follow-up results

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a prevalent and disabling condition with frequent chronic course. Staging models applied to psychiatric disorders seek to define their extent of progression at a particular time-point and differentiate early, milder clinical phenomena from those characterizing illness progression and chronicity. In OCD patients, a staging model has been recently proposed but not tested yet. This was the aim of the present study.

METHODS

From an overall sample of 198 OCD patients, recruited across two psychiatric clinics in Northern Italy, 70 patients on stable treatment completed a follow-up assessment ranging from 12 to 24 months. At follow-up initiation, patients had been divided into four staging groups, according to the model proposed by Fontenelle and Yucel. At the end of the follow-up, patients were subdivided into three groups (no stage change, improved stage, or worsened stage) compared with statistical analyses.

RESULTS

At the end of the follow-up, 67.1% patients showed no stage changes, 24.3% a stage improvement, and 8.6% a stage progression. Worsened patients showed higher rates of comorbid disorders and higher rates of unfavorable employment characteristics compared to the other subgroups (P < .05). Patients with worsened stage showed higher prevalence of somatic obsessions (P < .05), while patients with improved stage showed higher rates of magical thinking and violence/harm obsessions compared to other groups (P < .05).

DISCUSSION

The present results provide epidemiologic and clinical correlates of the first application of a staging model in a sample of OCD patients, encouraging further studies to assess the utility of this approach in the field.

Suicide mortality among psychiatric patients in Northeast Italy: a 10-year cohort study

AIMS

The present study investigated the relationship between suicide mortality and contact with a community mental health centre (CMHC) among the adult population in the Veneto Region (northeast Italy, population 4.9 million). Specifically, it estimated the effects of age, gender, time elapsed since the first contact with a CMHC, calendar year of diagnosis and diagnostic category on suicide mortality and modality.

METHODS

The regional mortality archive was linked to electronic medical records for all residents aged 18-84 years who had been admitted to a CMHC in the Veneto Region in 2008. In total, 54 350 subjects diagnosed with a mental disorder were included in the cohort and followed up for a period of 10 years, ending in 2018. Years of life lost (YLL) were computed and suicide mortality was estimated as a mortality rate ratio (MRR).

RESULTS

During the follow-up period, 4.4% of all registered deaths were from suicide, but, given the premature age of death (mean 52.2 years), suicide death accounted for 8.7% of YLL; this percentage was particularly high among patients with borderline personality disorder (27.2%), substance use disorder (12.1%) and bipolar disorder (11.5%) who also presented the highest suicide mortality rates. Suicide mortality rates were halved in female patients (MRR 0.45; 95% CI 0.37-0.55), highest in patients aged 45-54 years (MRR 1.56; 95% CI 1.09-2.23), and particularly elevated in the 2 months following first contact with CMHCs (MRR 10.4; 95% CI 5.30-20.3). A sensitivity analysis restricted to patients first diagnosed in 2008 confirmed the results. The most common modalities of suicide were hanging (47%), jumping (18%), poisoning (13%) and drowning (10%), whereas suicide from firearm was rare (4%). Gender, age at death and time since first contact with CMHCs influenced suicide modality.

CONCLUSIONS

Suicide prevention strategies must be promptly initiated after patients' first contact with CMHCs. Patients diagnosed with borderline personality disorder, substance use disorder and bipolar disorder may be at particularly high risk for suicide.

Prodromal Symptoms in Depression: A Systematic Review

INTRODUCTION

Appraisal of prodromal symptoms of unipolar depression may complement the traditional cross-sectional approach and provide a longitudinal perspective, according to a staging model of the illness.

OBJECTIVE

To provide an updated systematic review of clinical studies concerned with prodromal symptoms of unipolar depression, according to PRISMA guidelines.

METHODS

Keyword searches were conducted in PubMed, Scopus, and Web of Science. Longitudinal studies on prodromal symptoms and signs in adult patients primarily diagnosed with unipolar depression were selected. Findings were examined separately according to study design (i.e., retrospective or prospective).

RESULTS

Twenty-five studies met the criteria for inclusion in this systematic review. Findings indicate that a distinct prodromal symptomatology - commonly characterized by anxiety, tension, irritability, and somatic complaints - exists before the onset of unipolar depression. The duration of the prodromal phase was highly variable across studies, ranging from less than a month to several years. Prodromal symptoms profile and duration were consistent within individuals across depressive episodes. There was a close relationship between prodromal and residual symptoms of the same depressive episode.

CONCLUSIONS

The present systematic review addresses an important, and yet relatively neglected, clinical issue that deserves further investigation and may be of immediate practical value. The findings provide challenging insights into the pathogenesis and course of unipolar depression, which may result in more timely and effective treatment of recurrences. The definition of a prodromal phase in depression would benefit from the joint use of symptom identification, biomarkers, and neuroimaging.